Prasad G V Ramesh
Division of Nephrology, St. Michael's Hospital, University of Toronto, 61 Queen Street East, 9th Floor, Toronto, ON M5C 2T2 Canada.
Transplant Res. 2015 Jul 22;4:3. doi: 10.1186/s13737-015-0025-9. eCollection 2015.
Commercial transplant tourism results in significant harm to both kidney donors and recipients. However, proponents of incentives for kidney donation assert that proper oversight of the process prevents these harms and also that transplant numbers can be safely increased so that the moral burden of poor end-stage kidney disease outcomes can be alleviated. In a moral dilemma analysis, the principle of preventing donor harm can be dissociated from the principles of providing benefits to the recipient and to society. It is plausible that an incentivized donor is fundamentally different from an uncompensated donor. Incentivized donors can experience harms unrelated to lack of regulation because their characteristics are determined by the incentive superimposed upon a poverty circumstance. Moreover, creating a system of incentivized donation without established national registries for capturing all long-term donor outcomes would be morally inconsistent, since without prior demonstration that donor outcomes are not income or wealth-dependent, a population of incentivized donors cannot be morally created in a clinical trial. Socioeconomic factors adversely affect outcome in other surgical populations, and interventions on income or wealth in these populations have not been studied. Coercion will be increased in families not affected by kidney disease, where knowledge of a new income source and not of a potential recipient is the incentive. In the case of elective surgery such as kidney donation, donor non-maleficence trumps donor autonomy, recipient beneficence, and beneficence to society when there is a conflict among these principles. Yet, we are still faced with the total moral burden of end-stage kidney disease, which belongs to the society that cannot provide enough donor kidneys. Acting according to one arm of the dilemma to prevent donor harm does not erase obligations towards the other, to provide recipient benefit. To resolve the moral burden, as moral agents, we must rearrange our institutions by increasing available donor organs from other sources. The shortage of donor kidneys creates a moral burden for society, but incentives for donation will only increase the total moral burden of end-stage kidney disease.
商业性移植旅游对肾脏供体和受体都会造成严重伤害。然而，支持对肾脏捐赠给予激励措施的人声称，对该过程进行适当监督可防止这些伤害，而且移植数量能够安全增加，从而减轻终末期肾病不良后果带来的道德负担。在道德困境分析中，防止供体受到伤害的原则可与给受体和社会带来益处的原则相分离。有激励措施的供体与无补偿的供体在本质上可能存在差异，这是有道理的。有激励措施的供体可能会遭受与缺乏监管无关的伤害，因为他们的特征是由叠加在贫困状况之上的激励因素所决定的。此外，在没有建立全国性登记系统来记录所有供体长期结果的情况下，建立一个有激励措施的捐赠系统在道德上是不一致的，因为在没有事先证明供体结果不依赖于收入或财富的情况下，就无法在临床试验中从道德层面创造出一批有激励措施的供体。社会经济因素会对其他外科手术人群的治疗结果产生不利影响，而针对这些人群的收入或财富干预措施尚未得到研究。在未受肾病影响的家庭中，由于知晓新的收入来源而非潜在受体是激励因素，胁迫情况将会增加。在诸如肾脏捐赠这样的择期手术中，当这些原则之间存在冲突时，供体不伤害原则优先于供体自主原则、受体受益原则和对社会的受益原则。然而，我们仍然面临着终末期肾病的全部道德负担，这属于无法提供足够供体肾脏的社会。根据困境的一方面采取行动以防止供体受到伤害，并不能消除对另一方面的义务，即给受体带来益处。为了解决道德负担，作为道德主体，我们必须通过增加来自其他来源的可用供体器官来重新调整我们的制度。供体肾脏的短缺给社会带来了道德负担，但捐赠激励措施只会增加终末期肾病的总体道德负担。
